Implementing CSTK Measures at a High Volume Comprehensive Stroke Center

Background: The Joint Commission mandates implementation of comprehensive stroke (CSTK) measures for Comprehensive Stroke Centers (CSC) effective January 1, 2015. CSTK measures are evidence based metrics targeting quality of care and outcomes for stroke patients. Purpose: Share challenges and experiences in implementation of CSTK measures, and present our data highlighting these metrics. Methods: Beginning last quarter of 2014 we reviewed the guidelines in multidisciplinary CSC committees, identified the measure specific needs, and assigned responsibilities to team members. We started pilot data collection and re-programmed our CSC data registry to capture these data. We also created live dashboards to provide instant feedback on performance metrics (Fig 1). All CSTK measures were incorporated to the stroke coordinators’ daily review, with emphasis on concurrent follow up, hence preventing fall outs. This approach enabled us to monitor our progress, identify performance improvement opportunities, and develop evidence based PDSA cycles. Efforts were undertaken to train and educate clinical staff, develop process specific scripts and algorithms, and periodically present data for internal review. Results: We obtained comprehensive stroke certification in March 2013 and re-certification in June 2015. From January 2014 to April 2015 we treated 2,886 patients (180 patients per month). Meeting the requirements entailed enhanced clinical documentation, alterations in work flow, additional time and resources for tracking data elements, and monitoring. Our CSTK metrics for indicated time periods are presented as Fig 2a - 2j. Conclusion: The eight CSTK measures encompass a wide range of system processes. Workflow alterations in a complex health care environment can be daunting. We share our experiences, and provide a successful model for our peers, particularly generalizable for high throughput centers.